Flat Foot (Pes Planus) PT Protocol

The main priority for 99% of all flat foot patients is to stretch the calf, and more specifically the gastrocnemius muscle. The gastroc and the soleus are going to “win” any battle for the alignment foot since it has a 10:1 strength ratio to the rest of the leg muscles.

Medical language for Physical Therapists: If the calf is tight, then the patient will compensate into lateral peritalar subluxation by everting the hindfoot. This leads to both impingement at the sinus tarsi (lateral hindfoot pain) and tension tendinitis/failure at the tibialis posterior tendon (PTT). In that positioning, the medial forefoot (first ray) is the lowest part of the forefoot and will therefore eventually become hypermobile at the 1st TMT joint and dorsiflex at that joint (apex plantar angulation with gapping at the base of the 1st TMT joint on lateral xray). This hypermobility of the medial column is both in the sagittal plane and also in the axial plane. Axial plane hypermobility leads to abduction of the 1st metatarsal. Shoes adduct the great toe and, along with improper gait where the patient rolls off the medial aspect of the great toe (instead of off the plantar aspect of the great toe) and combine to give the result of hallux valgus (bunion).

Therefore, the priority of therapy is to get the calf (gastroc) out of the way of the rest of the musculature and then strengthen the muscles that hold the arch up. See below:

  1. Gastroc stretching (link)
    • Strap/towel stretch
    • Stair stretch
    • Never the wall stretch or “runner’s stretch” (it doesn’t work!)
    • If stretching does not work, you may need to have a calf (gastroc) release to jump-start the process
  2. Arch Supporting and Elevation muscles: Tibialis Posterior and Peroneus Longus
    • Tibialis posterior strengthening
      • Cross legs and use theraband hooked around the other foot to redirect the force to pull the foot into eversion. Work the tibialis posterior muscle by going against the theraband and inverting the foot against resistance. Repeat
        Tibialis posterior strengthening

        Right Foot: Starting Position
        Tibialis posterior strengthening
        Right Foot: Ending Position
      • Medial foot dips: put just the lateral border of the foot on a book and then allow the rest of the foot to rest on the ground. Lift entire body weight on just the lateral part of the foot that is on the book, then go back down. Repeat.

        Medial foot dip starting positionMedial foot dip starting position

        Medial foot dip lowest pointMedial foot dip lowest point
        Photo Sep 07, 2 07 41 PM
        Medial foot dip ending position
    • Peroneus longus strengthening
      • Isometric reps of depression of the first metatarsal head. This can be done any time during the day, even while wearing shoes.
      • Lateral foot dips: put just the first metatarsal head on a book and then allow the rest of the foot to rest on the ground. Lift entire body weight on just the ball of the foot that is on the book, then go back down. Repeat. (This exercise is similar to, but opposite what is shown for “Medial foot dips”)
      • Another great dynamic exercise for the peroneus longus (and all of the other key “arch muscles”) is to just run in place with a springy step. Yep, that’s right. Running in place is a great way to put everything you need to do into one single exercise.
  3. Intrinsic Strengthening
    • NOT needed, because:
      • The intrinsics DO NOT hold the arch up. The two muscles above do.
      • They are already strong in these patients.
    • If you test the intrinsic strength of patients with flat feet, you’ll see that they actually have the strongest intrinsics of any patients. This could be due to the fact that they are constantly lengthening them with every step as the foot is forced into lateral peritalar subluxation. This eccentric loading of the intrinsic muscles is the best way to hypertrophy any muscle.
    • The patients who need intrinsic strengthening are almost always those with excessively high arches (pes cavus).
  4. Putting it all together
    • A great video summarizing how to activate the arch musculature while standing. This might be the most important thing to do of anything on this entire page because it’s something you can do any time, all the time: Stand and walk while trying to re-create your OWN arch.

    • If you are a runner, then running with a “natural running” stride and form can actually bring your arch up. Running correctly will do all of the exercises listed above with every step and will do them in the correct proportion and balance.
      • Informal case study by Nick Campitelli, DPM of arch dynamics improving after 2 years of running with good natural (“minimalist”) running form and footwear
    • Another way to put it all together is to walk with the toes pointed straight ahead. (Click here for more information about this) This forces you to work the two muscles listed above (as long as you are pushing off the great toe and it is spread apart from the other toes correctly).
    • Running in place: similar benefits to running, but impossible to do wrong. If you’re running in place, you have perfect running form.

Custom “Arch Supports”

A word about “arch supports.” Simply put: they don’t work (and another link). No study has ever shown that they improve (let alone change) anyone’s arch at all. Sometimes, they can be useful as a short-term crutch, as discussed by Nick Campitelli, DPM. What arch supporting shoe inserts DO achieve is to place pressure and cause pain on a part of the foot that was never designed to bear weight. If the arch was designed to bear weight, it would have been the lowest part of the foot. Instead, it is the only part of a healthy foot that does NOT touch the ground.

Should I buy shoes with good “support?”

Shoes that “support” the foot more and actually doing more harm than shoes that are less supportive or are completely flat inside. Supportive shoes with all kinds of patented motion-control and “corrective” technologies will actually weaken a foot and can lead to exactly the thing they are saying that they will prevent: an abnormal foot (flat foot or excessively high arched-foot). Imagine that you wore a back brace from the time you were 2 years old until you were an adult. Would you back be stronger and better formed? Or weaker and non-functional? Shoes are like braces for the feet. Instead of wearing braces, people (especially kids) should think of shoes as “clothes for the feet.” That means that shoes should protect us from the elements (thorns and sharp rocks, etc), and look good, but should not brace, weaken, or otherwise mess with the normal functioning of the human foot.


Back to Clinical Summary of Lower Extremity Protocols